Puerperal fever

Disease Description (Causes and Symptoms)

• Definition: Refers to a condition in which, during the period excluding the first 24 hours after childbirth (within 10 days postpartum), the oral temperature is 38℃ or higher for at least two days among temperatures measured four times a day (clinical criteria).
• Causes and pathophysiology: Bacteria present in the vagina, cervix, or uterus during or immediately after delivery may proliferate, or infection may develop in a cesarean-section wound, perineal suture site, or retained uterine material (such as part of the placenta), spreading through an ascending infection or wound infection. Pathogens include group A streptococci, staphylococci (Staphylococcus aureus), intestinal bacteria such as Escherichia coli, anaerobic bacteria, and, rarely, gonococci. If it spreads systemically, it may progress to sepsis.
• Main symptoms: Fever (possibly accompanied by chills), lower abdominal pain and uterine tenderness, perineal pain, swelling, and oral discharge (which may have a foul odor), painful urination and urinary frequency (when cystitis is also present), and breast pain (when mastitis is also present). In severe cases, tachycardia, hypotension, and altered consciousness (signs of sepsis) may occur.

Treatment Methods

• Diagnostic tests: Temperature tracking, physical examination (uterine size and tenderness, wound and breast examination), blood tests (CBC, CRP, blood culture), urinalysis and urine culture, wound and vaginal discharge cultures, and pelvic ultrasound (to check for retained material or abscesses).
• Antibiotic treatment: If puerperal fever is clinically suspected, empiric broad-spectrum antibiotics should be started promptly.
  • Commonly used empiric regimens: A combination of intravenous clindamycin + gentamicin (or an aminoglycoside), or a combination of ampicillin/ampicillin-sulbactam + an aminoglycoside/metronidazole. If severe infection or hospital-acquired organisms are suspected, piperacillin–tazobactam or a carbapenem may be considered.
  • Adjust antibiotics according to culture results.
• Local treatment and surgical treatment: If retained material in the uterus (e.g., retained placenta) is present, it is removed by curettage; an abscess at a suture site is treated with incision and drainage; and pelvic or intra-abdominal abscesses may require drainage (surgical or percutaneous drainage). Intensive care unit management may be required for severe infection or sepsis.
• Supportive care: IV fluids, antipyretics and analgesics, and oxygen therapy (if necessary). If mastitis is also present, appropriate drainage and continuation of breastfeeding are recommended for breastfeeding and breast care (confirm breastfeeding compatibility for each medication).
• Prevention and precautions: Appropriate preoperative prophylactic antibiotics during cesarean section, adherence to aseptic technique, perineal hygiene, and education on wound-disinfection methods after discharge. Monitor for allergies and adverse effects while taking antibiotics.

Checklist Before an Outpatient Visit (Including Example Questions)

• Items and records to prepare:
  • Recent temperature records (if possible, four times a day, including when the fever began)
  • Records of the location and intensity of pain (pain scale), and the color, odor, and amount of discharge, as well as urinary symptoms
  • Delivery information: date of delivery, vaginal or cesarean delivery, whether an episiotomy or suturing was performed, whether retained placenta was present, etc.
  • List of medications currently being taken (including antibiotics) and history of allergies
  • Recent test results (test results from hospitalization, CBC, etc.) and photos (wound condition, discharge, etc.)
• Key information to provide to the doctor at the outpatient visit:
  • When the fever began and its pattern (how many times a day and the highest temperature)
  • Condition of the wound (suture site) and treatment history
  • Whether breastfeeding and the condition of the breasts

General Example Questions to Ask the Doctor

• What are the common side effects and precautions for this medication (the prescribed antibiotic)?
• How long is treatment expected to last, and what is the prognosis? When can I expect to return to normal?
• Is hospitalization necessary, or is outpatient antibiotic treatment sufficient? What are the criteria?
• I am breastfeeding; will taking this medication affect my baby? Can I continue breastfeeding?
• How should I care for the wound and maintain hygiene after discharge? When can I resume normal activities (showering, exercise, etc.)?

Examples of Condition-Specific Questions

• The fever and pain are continuing. If the fever persists for how long (how many hours or days) should I go to the emergency room immediately?
• An abscess is suspected in the cesarean-section wound (or perineal suture site). Can you check right now whether suture removal or incision and drainage is necessary?
• If retained material in the uterus is suspected on ultrasound, is curettage necessary? What does the procedure involve, and what are its risks?

Additional guidance: If symptoms (such as high fever, tachycardia, hypotension, or altered consciousness) are severe or worsening rapidly, immediately visit an emergency medical institution or seek evaluation in an emergency room.